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Background: Vitamin C at high concentrations is toxic to cancer dose. Vitamin C at a dose of 1.25 g administered orally produced
cells in vitro. Early clinical studies of vitamin C in patients with mean (SD) peak plasma concentrations of 134.8 20.6 mol/L
terminal cancer suggested clinical benefit, but 2 double-blind, compared with 885 201.2 mol/L for intravenous administra-
placebo-controlled trials showed none. However, these studies tion. For the maximum tolerated oral dose of 3 g every 4 hours,
used different routes of administration. pharmacokinetic modeling predicted peak plasma vitamin C con-
centrations of 220 mol/L and 13 400 mol/L for a 50-g intra-
Objective: To determine whether plasma vitamin C concentra- venous dose. Peak predicted urine concentrations of vitamin C
tions vary substantially with the route of administration.
from intravenous administration were 140-fold higher than those
Design: Dose concentration studies and pharmacokinetic model- from maximum oral doses.
ing.
Limitations: Patient data are not available to confirm pharma-
Setting: Academic medical center. cokinetic modeling at high doses and in patients with cancer.
Participants: 17 healthy hospitalized volunteers. Conclusions: Oral vitamin C produces plasma concentrations
that are tightly controlled. Only intravenous administration of
Measurements: Vitamin C plasma and urine concentrations vitamin C produces high plasma and urine concentrations that
were measured after administration of oral and intravenous doses might have antitumor activity. Because efficacy of vitamin C treat-
at a dose range of 0.015 to 1.25 g, and plasma concentrations ment cannot be judged from clinical trials that use only oral
were calculated for a dose range of 1 to 100 g. dosing, the role of vitamin C in cancer treatment should be re-
evaluated.
Results: Peak plasma vitamin C concentrations were higher after
administration of intravenous doses than after administration of Ann Intern Med. 2004;140:533-537. www.annals.org
oral doses (P < 0.001), and the difference increased according to For author affiliations, see end of text.
Plasma vitamin C concentrations are shown as a function of time after the 1.25-g oral or intravenous dose administered at steady state for that dose in
12 persons (3 men, 9 women). Inset: Peak plasma vitamin C concentrations as a function of dose after oral or intravenous administration of vitamin C.
Seventeen persons (7 men, 10 women) received doses from 0.015 to 0.1 g, 16 persons (6 men, 10 women) received the 0.2-g dose, 14 persons (6 men,
8 women) received the 0.5-g dose, and 12 persons (3 men, 9 women) received the 1.25-g dose. Persons received each dose while at steady state for that
dose.
achieved by maximum oral consumption. Both findings However, consumption of fruits and vegetables, which
have clinical relevance. contain vitamin C, is beneficial for unknown reasons (16,
Vitamin C oral supplements are among the most pop- 17). On the basis of current knowledge and the pharma-
ular sold, and gram doses are promoted for preventing and cokinetics presented here, physicians should advise their
treating the common cold, managing stress, and enhancing patients to consume fruits and vegetables, not vitamin C
well-being (1). Our data show that single supplement gram supplements, to obtain potential benefits.
doses produce transient peak plasma concentrations that at Just as important, our data show that intravenous ad-
most are 2- to 3-fold higher than those from vitamin ministration of vitamin C produces substantially higher
Crich foods (200 to 300 mg daily). In either case, plasma plasma concentrations than can be achieved with oral ad-
values return to similar steady-state concentrations in 24 ministration of vitamin C. This difference was previously
hours. Because differences in plasma concentrations from unrecognized and may have treatment implications. Case
supplements and from food intake are not large, supple- series published by Cameron, Campbell, and Pauling (l, 6,
ments would be expected to confer little additional benefit, 7) have been controversial. In these series, several hundred
a finding supported by available evidence (16, 17). patients with terminal cancer treated with 10 g of vitamin
www.annals.org 6 April 2004 Annals of Internal Medicine Volume 140 Number 7 535
Figure 2. Predicted plasma vitamin C concentrations in healthy persons after oral (top) or intravenous (IV ) (bottom)
administration of vitamin C.
The 3-compartment pharmacokinetic model used to calculate these values was derived from data in 7 healthy men (3, 14). Baseline values are 70 to 85
mol/L, the expected steady-state plasma vitamin C concentration for healthy persons with a vitamin C intake of more than 0.2 g/d.
C intravenously for 10 days and then 10 g orally indefi- with intravenous administration. The Mayo Clinic studies
nitely were compared with more than 1000 retrospective neither support nor refute possible effects of intravenously
and prospective controls. Patients treated with vitamin C administered vitamin C on cancer.
survived 150 to 300 days longer than controls (1, 6, 7). Intravenous vitamin C may have a role in the treat-
Other researchers reported benefit consisting of increased ment of cancer as a result of the plasma concentrations that
survival, improved well-being, and reduced pain (1). All of can be achieved only by this route. With consumption of 5
these studies were uncontrolled, and factors unrelated to to 9 servings of fruits and vegetables daily, steady-state
intervention may have affected outcome. Two randomized, plasma concentrations are 80 mol/L or less, and peak
double-blind, placebo-controlled studies from the Mayo values do not exceed 220 mol/L, even after maximum
Clinic found no benefit (8, 9). These studies included 200 oral administration of 3 g 6 times daily. By contrast, intra-
patients who were treated with 10 g of vitamin C daily. venous vitamin C may produce plasma concentrations as
The Mayo Clinic studies were considered to be definitive high as 15 000 mol/L. At extracellular concentrations
(10). However, in these studies, vitamin C was given greater than 1000 mol/L, vitamin C is toxic to cancer
orally, which is in contrast to the intravenous and oral use cells, although mechanisms and interpretation are contro-
in other studies. On the basis of our pharmacokinetic data, versial (11, 12, 18). The vitamin C free radical species,
we conclude that the Mayo Clinic studies, which used oral ascorbyl radical, is detectable in animals only when they
administration of vitamin C, are not comparable to studies receive intravenous vitamin C equivalent to a 10-g dose in
536 6 April 2004 Annals of Internal Medicine Volume 140 Number 7 www.annals.org
humans (19). We propose that detectable ascorbyl radical allowance of vitamin C for healthy young women. Proc Natl Acad Sci U S A.
2001;98:9842-6. [PMID: 11504949]
forms only when human plasma concentrations are greater
5. McCormick WJ. Cancer: a collagen disease, secondary to a nutritional defi-
than 1000 mol/L and that either the radical itself or its ciency. Arch Pediatr. 1959;76:166-71. [PMID: 13638066]
unpaired electron induces oxidative damage that can be 6. Cameron E, Campbell A. The orthomolecular treatment of cancer. II. Clinical
repaired by normal but not cancer cells. Understanding trial of high-dose ascorbic acid supplements in advanced human cancer. Chem
mechanisms of cytotoxicity may further the investigational Biol Interact. 1974;9:285-315. [PMID: 4430016]
use of vitamin C in patients with cancer, used alone or 7. Cameron E, Pauling L. Supplemental ascorbate in the supportive treatment of
with other agents that potentiate such actions (20). Al- cancer: reevaluation of prolongation of survival times in terminal human cancer.
Proc Natl Acad Sci U S A. 1978;75:4538-42. [PMID: 279931]
though minimal data are available, intravenous vitamin C 8. Creagan ET, Moertel CG, OFallon JR, Schutt AJ, OConnell MJ, Rubin J,
is expected to have little toxicity compared with conven- et al. Failure of high-dose vitamin C (ascorbic acid) therapy to benefit patients
tional chemotherapeutic agents (3). In this context and in with advanced cancer. A controlled trial. N Engl J Med. 1979;301:687-90.
light of our new pharmacokinetic data, a role for intrave- [PMID: 384241]
nous vitamin C in cancer treatment should be reevaluated. 9. Moertel CG, Fleming TR, Creagan ET, Rubin J, OConnell MJ, Ames
MM. High-dose vitamin C versus placebo in the treatment of patients with
advanced cancer who have had no prior chemotherapy. A randomized double-
From the National Institute of Diabetes and Digestive and Kidney Dis-
blind comparison. N Engl J Med. 1985;312:137-41. [PMID: 3880867]
eases, the National Cancer Institute, and the Clinical Center, National
10. Wittes RE. Vitamin C and cancer [Editorial]. N Engl J Med. 1985;312:
Institutes of Health, Bethesda, Maryland; the Food and Drug Adminis-
178-9. [PMID: 3965937]
tration, Rockville, Maryland; and Bio-Communications Research Insti-
11. Leung PY, Miyashita K, Young M, Tsao CS. Cytotoxic effect of ascorbate
tute, Wichita, Kansas.
and its derivatives on cultured malignant and nonmalignant cell lines. Anticancer
Res. 1993;13:475-80. [PMID: 8517665]
Grant Support: By a grant from the National Institute of Diabetes and
12. Sakagami H, Satoh K, Hakeda Y, Kumegawa M. Apoptosis-inducing activ-
Digestive and Kidney Diseases, National Institutes of Health (Z01 DK ity of vitamin C and vitamin K. Cell Mol Biol (Noisy-le-grand). 2000;46:129-43.
54506). Dr. Katz received partial support from the Office of Dietary [PMID: 10726979]
Supplements, Office of the Director, National Institutes of Health. 13. Padayatty SJ, Levine M. New insights into the physiology and pharmacology
of vitamin C. CMAJ. 2001;164:353-5. [PMID: 11232136]
Potential Financial Conflicts of Interest: None disclosed. 14. Graumlich JF, Ludden TM, Conry-Cantilena C, Cantilena LR Jr, Wang Y,
Levine M. Pharmacokinetic model of ascorbic acid in healthy male volunteers
Requests for Single Reprints: Mark Levine, MD, Molecular and Clin- during depletion and repletion. Pharm Res. 1997;14:1133-9. [PMID: 9327438]
ical Nutrition Section, Building 10, Room 4D52MSC 1372, National 15. Washko PW, Welch RW, Dhariwal KR, Wang Y, Levine M. Ascorbic acid
Institutes of Health, Bethesda, MD 20892-1372. and dehydroascorbic acid analyses in biological samples. Anal Biochem. 1992;
204:1-14. [PMID: 1514674]
Current author addresses and author contributions are available at www
16. Padayatty SJ, Katz A, Wang Y, Eck P, Kwon O, Lee JH, et al. Vitamin C
.annals.org.
as an antioxidant: evaluation of its role in disease prevention. J Am Coll Nutr.
2003;22:18-35. [PMID: 12569111]
17. Fairfield KM, Fletcher RH. Vitamins for chronic disease prevention in
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